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Fourth: In regard to measures for immediate relief, we may observe such rules as follows:

1. In any fracture, simple or compound, in which there are cerebral symptoms, it is proper to incise the scalp and trephine.

2. In cases where we find depression without any cerebral symptoms, but there is a possibility of future trouble, I think we should trephine.

3. In cases where we find punctured fractures, as those made by a knife, etc., the rule has long since been absolute to trephine, and if necessary open the dura and disinfect. These punctured fractures give a higher mortality as a rule than the others.

4. If we find a simple fracture without any cerebral symptoms we may pursue the expectant plan, and if any symptoms develop then trephine. Wagner some years ago gave statistics of eighty-one cases of compound fracture of the skull which were treated immediately by trephining with a mortality of 1.23 per cent, while twelve cases treated by trephining some time after the injury gave a mortality of 33.5 per cent.

CASE 1. W. R., male, aged thirteen, was struck with a rock on the left parietal prominence on Tuesday, September 7, 1897. At the time he noticed that his hand on the opposite side jumped, and that there was slight loss of sensation; except headache he felt very well until the following Saturday, and on that day he had convulsions. At the request of his physician I saw him Sunday. I advised operation at once. He was sent to the infirmary; circumstances which we could not control prevented us from operating until the next day. He had four convulsions Sunday and six Sunday night, and complete paralysis in right arm. I operated on Monday morning, taking all the necessary antiseptic precautions. A Aap, which was one half circle, diameter of which was more than two inches, was made, which exposed a depressed fracture the size of a five-cent piece. The edge of the trephine was placed at the upper margin of the fracture; a button of bone five eighths of an inch was removed, finger inserted, and fracture elevated; at this point a most violent hemorrhage took place, which was with great difficulty stopped. The button was not replaced; the edges of the wound were approximated with silk sutures. The wound was dressed and the boy removed from the operating-room with a pulse of 124. Morphine was ordered hypodermically to keep him quiet. The next day his pulse was increased to 140, later fell to 120, stayed there until evening, when it fell to 108. Fearing dislodgment of the clot in the artery, from which he had such

a profuse hemorrhage, I withheld all stimulants. I ordered one pint normal salt solution thrown into the bowel, which he retained. On the third day pulse was 100 and of good quality. He continued to improve, and on the following Friday stitches were removed; the wound had healed; a light dressing was applied.

His diet was increased, his paralysis and convulsions had disappeared, and he was dismissed from the infirmary on the twelfth day.

CASE 2. R. W., male, aged nineteen, received a blow over the right ear. There was considerable hemorrhage and loss of brain tissue. The wound was dressed at the time by Dr. Switzer. I advised the patient to come to the city, where I could attend him. He was sent to the infirmary, and upon examination I found a compound fracture of the squamous portion of the temporal bone. The brain and its membranes were torn badly. His head was shaved, and tincture green soap poultice was applied. The other precautions against infection were carried out the next morning at the operation. The scalp was cut in such a manner it was impossible to make the ordinary horse-shoe flap, so a straight incision was made, which exposed the fracture. Pieces of bone which were driven into the brain were removed with thumb forceps until the jaws of a Rongeur forceps could be inserted, when the opening was made larger in order to remove one large piece of bone which was deeply imbeded into the brain. After this was removed, considerable amount of brain tissue escaped. The edges of the bone were smoothed; the wound was disinfected. The membranes were so badly torn they could not be sutured, so closure of the wound with silk tures with drainage was promptly done. The necessary dressing was applied, and boy removed from operating-room in good condition. Nothing eventful occurred; he was on light diet; drain was removed twenty-four hours later and not replaced; stitches were removed on the following Friday, and he was dismissed on the fourteenth day after operation.




There seems recently to have arisen a popular clamor against the use of starchy substances as food; so much so, indeed, that some have gone so far as to urge the abolition of bread, the principal source from which starch as a food is obtained, entirely from our tables. I suppose, however, this is only the extreme oscillation of the pendulum with the overzealous since special attention has been directed to starch food and the part its imperfect digestion plays in the production of disease.

In the brief consideration of the subject contemplated in this paper, it will be my purpose to refer, first, to the use of starch as a food and the importance of its use in the animal economy; second, to its abuse, and how such abuse is brought about, and, third, the best means to correct its evil effects when injudiciously used.

First, as to the food value of starch. It has been said that the whole grain of the wheat cereal contains about every thing necessary to the repair of the physical man when properly prepared and prudently partaken of. Not only man, but nearly all the lower order of animals find a most valuable and a favorite food in the various cereals and other vegetable products containing amyloid and albuminoid elements in their varying proportions. So it is with all kinds of birds, and even fishes are fond of bread crumbs and forms of food obtained from plant seeds.

But it is only the amylaceous portion of our food that claims our attention at present. This is very much the larger portion of the grain of all cereals. The wonderful wisdomn displayed in the general use of starch by the animal creation is attested by the purpose it subserves in the animal economy-a purpose absolutely necessary to the maintenance of body heat, and consequently to the maintenance of life.

In order that the starch may be appropriated to the wants of the system, it is necessary that it should pass through various processes and be transformed into various other substances. To successfully accomplish its purposes, it is necessary that it be well cooked, well masticated, and thoroughly mixed with the saliva before its introduction into the stomach. The paramount importance of its being thor

* Read before the Southern Kentucky Medical Association at Bowling Green, Norember 3-4, 1897

oughly inixed with the saliva should not be passed over without something more than a passing notice. Saliva, with its ptyalin, is the principal ferment and digestive agent of starchy matters, just as gastric juice, with its pepsin, is the principal instrument in the solution and digestion of albuminoids. If the starch should not obtain a sufficient admixture with saliva while in the mouth to effect its digestion, as it fails to get any aid from the stomach juices, it is likely, while contained in that organ, to be subjected to an abnormal form of fermentation with the evolution of gas, and become so decomposed that it becomes entirely unfit for the purpose it was intended to subserve, and it thus becomes an irritant to the stomach and bowels, as will be referred to and demonstrated further on.

Having then been thoroughly masticated and insalivated, it passes into the stomach, and before the acid of the gastric juice has had time to be secreted in sufficient quantity to neutralize the alkaline saliva, the starch has been sufficiently digested to pass along with the other food out of the stomach, which has been merely a side station for it while on its way to the liver.

The pancreatic juice completes its intestinal digestion, converting it into glucose, and it is taken up by the veins and carried to the liver, where it is again transformed into glycogen and stored up for future

When it is drawn upon for use in the system, it is again changed into lactic acid, which is the form necessary for its combustion in the various tissues of the body, and thus it is appropriated to the maintenance of the body heat. So much for its use and purpose, and for the manner in which it is appropriated to effect that purpose.

We will now pass to the second section of the subject, viz., the abuse of this most valuable substance. An agent so potent for good is usually equally potent for evil if misused or abused. I presume it will be readily conceded that most of the dyspepsias, gastric catarrhs, and other stomach disorders are attributable to the imperfect digestion of starch, coupled with eating too much. The main purpose of this paper is to endeavor to show how these dire complaints are the legitimate and almost inevitable result of a failure to properly digest starch.

We live in a bustling, hurrying, restless age, and especially in that character of country. We are taught, or at least encouraged, by precept and example from our infancy up, to complete the eating act in as short a time as possible-to bolt our food unmasticated, it being washed down by large draughts of fluid. Our railway eating-houses


seem to have set the pace for most of our family tables. The starch thus utterly fails to get its due proportion of saliva, which is absolutely necessary for its healthy digestion, while the albuminoids in the form of lean meats, eggs, cheese, and the glutinous portion of bread are unmasticated, and this throws double duty on the stomach. The stomach, partly by reason of this double duty and partly from excessive indulgence in table comforts, finally becomes exhausted and fails to honor the drafts made upon it in the digestion of the albuminoids, while the undigested starch is decomposed into irritable and corrosive acids and large volumes of sour gas, by reason of the warmth and moisture of the stomach, and the sugar taken more or less with each meal.

This gas in its turn, in the process of time, distends the stomach walls like a blown up bladder, presses it up against the diaphragm and heart, producing pains, smothering, palpitations, intermission, and all sorts of functional disturbances of that very sensitive and sympathetic organ. These acrid corrosive acids generated by decomposing starch, coupled with distension of the stomach by gases and overeating, result in chronic catarrhal inflammation of that organ, producing a glairy, tenacious mucus which mechanically coats and covers over the food taken into the stomach, and thus defeats the action of the gastric Auid on the albuminoids. In this condition the stomach is rarely empty of food, and never clear of this ropy, catarrhal mucus. The abundant evolution of gas incident to this state of things gradually dilates the stomach walls till frequently the organ occupies pretty much all the epigastric, left hypochondriac, and left infra-axillary regions, thus compressing the lower and middle lobes of the left lung and displacing the heart from its normal position. This condition of gastrectasia, developed in greater or less degree, exists in an alarming number of cases, and I believe I am safe in attributing nine tenths of them to the imperfect digestion of starch.

Since sugar has become so cheap, it is lavishly used by all classes in the different forms of toothsome dishes, and when these are coupled, as they generally are, with imperfectly digested amyloid substances, we may alınost tremble for the future, for these stomach disturbances are growing more frequent daily, and are likely to continue if a better state of hygiene is not established.

How can these diseases be prevented, and how can they be successfully treated after they are developed ? To prevent them we want

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